MINOCA

U nawet 25% pacjentów z ACS w angiografii wieńcowej nie stwierdza się istotnego przewężenia w nasierdziowych tętnicach wieńcowych. Z reguły są to młodsze kobiety bez czynników ryzyka. Jest to grupa pacjentów bardzo heterogennych, o bardzo zróżnicowanym rokowaniu, często równie poważnym jak NSTEMI czy STEMI.

Autorzy aktualnych wytycznych definiują MINOCA jako:

  • ACS według kryteriów uniwersalnej definicji zawału
  • brak istotnych przewężeń (>50%) w nasierdziowych tętnicach wieńcowych
  • niestwierdzenie innej klinicznie istotnej przyczyny ostrej prezentacji.

Postępowaniem z wyboru jest poszerzenie diagnostyki interwencyjnej o obrazowanie wewnątrznaczyniowe oraz ocenę funkcjonalną tętnic wieńcowych. U pacjentów należy przeprowadzić diagnostykę nieinwazyjną (w tym obrazowanie metodą rezonansu magnetycznego) w celu wykluczenia innych klinicznych przyczyn ostrej prezentacji (miocarditis, zespół takotsubo).

Prawidłowo przeprowadzona diagnostyka pozwoli precyzyjnie ustalić, czy mamy do czynienia z erozją/pęknięciem blaszki miażdżycowej, samoistnym rozwarstwieniem tętnicy wieńcowej, chorobą mikronaczyniową czy spazmem tętnicy wieńcowej. Zastosowanie opisanych powyżej technik w rutynowej diagnostyce pacjentów z ACS umożliwia ustalenie rozpoznania, wdrożenie skutecznego leczenia i ocenę rokowania. Według wytycznych ESC takie postępowanie ma klasę zaleceń I, poziom C.

Abstract

Invasive coronary diagnosis procedures

Coronary angiography has many limitations. It does not allow assessing coronary vessel walls or the morphology and features of atherosclerotic plaque. Advanced intracoronary imaging modalities like intravascular ultrasound (IVUS) or optical coherence tomography (OCT) are nowadays essential for proper diagnosis of coronary artery diseases. IVUS allows measuring several vessel parameters: plaque burden, plaque distribution, artery diameter and many other which are necessary for planning therapeutic endovascular procedures. The role of advanced imaging modalities is especially important in diagnosis of acute coronary syndromes. Identifying unstable coronary plaque – TCFA (thin cup fibroatheroma) – by measuring fibrous cup thickness, minimal lumen area and circumferential extension of the lipid arch, and assessing the high atherosclerotic load is decisive for arriving at the right decision during percutaneous coronary interventions. IVUS is also required during percutaneous intervention in the left main coronary artery. Decision about stent size and length, optimal post-dilatation or possible application of two-stent technique in this site is crucial and has a direct influence on short- and long-term follow-up. IVUS is also recommended by guidelines on the diagnosis of specific clinical situations like MINOCA (myocardial infarction with non-obstructive coronary arteries) when establishing the final diagnosis based on angiography is difficult or impossible. IVUS combined with OCT is also recommended when spontaneous coronary dissection is under consideration. IVUS is very useful in diagnosis of mechanical problems associated with stent implantation like stent malapposition, underexpansion, fracture, edge dissection or restenosis (neointimal hyperplasia).

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